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This is the second of two posts prompted by Dr. Robert Centor’s critique of a recent New York Times Magazine article accusing America of “stealing [sic] the world’s doctors.” In the first post, I show how US immigration policy for physicians is a boondoggle of near-comedic proportions that doesn’t even constitute an effort at “theft,” given that it’s hard-pressed to hold onto me after I graduate (as I explain, I should be one of the easier doctors to “steal”).

Now let’s look at the counterfactual situation. Suppose the it were actually easy and straightforward for physicians to immigrate to the US (or to remain, in my case), gain licensure, and be certified in their specialties. Suppose the immigration and licensure systems were designed with this very goal in mind. Would this be a bad thing?

The conventional wisdom is that the emigration of skilled professionals from less to more-developed countries is bad for the less-developed countries: this process is often referred to as “brain drain.” Critics argue that “brain drain” harms poorer countries by preventing the development of local talent, skills, and professionals that are often sorely needed. They also point to the fact that many countries subsidize education at least to some extent, only to see the investment in their citizens’ human capital slip away beyond their shores.

Yet even this analysis misses the fundamental point. To insist, as the New York Times does, that foreign physicians somehow “belong” to their home countries is to objectify and commodify them. When you think about it, it’s a remarkable assumption for anyone to make. Foreigners are people too. We’re not chess pieces to be pushed around a board, traded for promises of foreign aid, trade preferences, or anything else one might imagine. The Canadian government has no more claim on me and my career than the American government does on anyone who has ever attended a public school in this country.

This is a universal principle. I don’t care how poor the country is, no government can claim to “own” its people in this way. It’s absurd to suggest that the United States government should alter its immigration policy to cater to other countries’ desire to engage in this form of subtle repression, and even more absurd to think that this would actually benefit anyone.

Physicians who voluntarily leave one country for another in the hopes of making a better life are not “being stolen.” Not unless you think they’re owned by someone other than themselves. At its core, that’s what this discussion is all about. And that’s why, in my mind, there should be no ambiguity as to the right conclusion.

Physicians for a National Health Plan (PNHP), as the name suggests, is the biggest and best-known group of American physicians who support replacing the current health care system with a national single-payer. I used to be a big booster of this idea, but it doesn’t take much poking around this website to figure out that my feelings towards American single-payer reform have cooled considerably (to say the least).
I’ve been fortunate to attend a number of events run by senior PNHP officers at SUMS and at other venues (e.g. the AMSA conference back in March). At one of the more recent events, I had the privilege of speaking at length to some of their representatives at length. As you might expect, the resulting discussion was direct but cordial.

Though I disagree with their proposed policies, I do respect PNHP as an organization. It is one of the biggest mobilizers of physicians and medical students who are in favour of radically changing how American health care operates. Their passion is palpable at even the most informal event. They do have a contribution to make to the health policy conversation. Unfortunately, while there is an intellectually-coherent case to be made for single-payer (a mistaken case, in my view, but respectable and honest), I have yet to hear it from anybody at PNHP (n=small).

I harbour no illusions about my ability to persuade hard-core single-payer believers in a short blog post. I do, however, have some friendly and hopefully helpful advice on how to talk to the uninitiated and the un-converted more productively:

1) Don’t try to twist the data to support your case. It shows. At best, data on Medicare-vs.-private administrative costs are equivocal, cross-country infant mortality comparisons are spurious, life expectancy at birth captures a lot of mortality that is out of the hands of the healthcare system, and so on. The empirical case for single-payer superiority is thin gruel.

2) When someone asks whether you’d trust a Republican President and Congress to implement single-payer well, don’t duck the question. It’s a more important one than you seem to acknowledge. If you want to centralize control in government, be prepared to talk about how you will deal with your ideological opponents who tend to win elections every now and then.

3) Your moral argument is a lot stronger than your empirical argument. Why not make it explicit? Americans don’t tend towards collectivism, but neither are most people data-oriented policy wonks. Instead of making a weak case based on weak data, you should be prepared to talk about the moral strengths of single-payer relative to the alternatives. Where are the mentions of equity, obligation, and collectivism? (I ask this seriously, not passive-aggressively)

4) Be fluent in the language business, politics, and economics. When your executives are being matched point-for-point by medical students who majored in biochemistry and similar fields, you know you have a problem. If you’re going to call for the dismantling of private insurance, have some idea of how the sector actually operates. If you want to give control of the health system to government, be able to discuss the nuances of Washington power structures. Be able to respond to phrases like “deadweight loss,” “price-vs.-income problems,” and “underwriting” with more than a blank stare.

5) Anecdotes are rarely dispositive of policy questions. When someone points this out about anecdotes involving people you know, don’t get offended; this rarely advances discussion. When you introduce your friend’s problems to the debate, it’s not your opponent who’s trying to use them to score “cheap points.”

6) Milton Friedman is said to have told an up-and-coming Walter Williams, after the latter appeared on TV to discuss school choice, that “[Williams] was right about everything but [had] made one mistake […], when you talk about liberty, you have to smile.” You may not be talking about liberty as Friedman understood the term, but his advice is every bit as applicable.

Given that the AAMC is one of the organizations raising the alarm about a looming physician shortage, it’s interesting to see that one of their responses is to ever-so-slightly raise the barrier to entry to medical school. That’s one heckuva cartel I’ve got on my side!

Of course, given the enormous mismatch between the number of medical school applicants and medical school spots, this change will not actually reduce the number of medical students (and as readers of this blog know, the real bottleneck is the number of residency slots). It will, however, increase the amount of time, effort, and money needed in order to meet the basic requirements for medical school admission. I suspect the test prep companies will fare especially well.

That said, I’m skeptical that the proposed MCAT changes are that worthwhile. I would be surprised if they do much, if anything, to address the concerns that seem to be motivating them. Here’s why.

1) Unless implemented very thoughtfully, inclusion of social science content will trivialize it by making it simply “another box to check” while studying. The USMLE has had limited success with this; can AAMC really do better?

The two recommendations from the the “MR5” report that seem to be driving much of the hubbub are these two:

3. Test examinees’ knowledge and use of the concepts in behavioral and social sciences, research methods, and statistics that provide a solid foundation for medical students’ learning about the behavioral and socio-cultural determinants of health.4. Test examinees’ ability to analyze and reason through passages in ethics and philosophy, cross-cultural studies, population health, and a wide range of social sciences and humanities disciplines to ensure that students possess the necessary critical thinking skills to be successful in medical school.

I’m on record as a fervent supporter of making statistical fluency a pre-requisite for entry to medical school (or a college degree, for that matter). If this change leads to an increase in the statistical literacy of future medical students, that’s a plus. Similarly, as a former economics major, I am fully aware of the applicability of various social science concepts and techniques to the medical field. If a standardized test can assess the ability to analyze ethical and philosophical problems, so much the better (though I would imagine that it would be more likely to measure familiarity with the key buzzwords from each discipline).

The risk of including these topics on the MCAT is that by making these disciplines part of “just another hoop to jump through,” the test won’t be able to adequately evaluate the analytical ability and engagement with the material that the AAMC seems to value. Lest you dismiss this as an idle concern, here’s an actual question from a gold-standard review book for the US Medical Licensing Exam. Step 1 of the USMLE includes questions on sociocultural topics, ethical topics, the doctor-patient relationship, and the same “cross-cultural studies” that will soon be added to the MCAT.

A 40-year-old woman who recently had back surgery does not complain of pain, although magnetic resonance imagery (MRI) reveal re-herniation of the disc with significant nerve involvement. Of the following, this woman is most likely to be of

[(A) is the correct answer, because “Anglo Americans tend to be more stoic and less vocal about pain than to Americans of Mediterranean or Latino descent”]

(from Fadem, B. Behavioral Science in Medicine. LWW, 2004. p. 326)

The chapter for which this question was written is entitled “Culture and Illness;” it reads like a checklist of stereotypes about various ethnic and cultural groups. I have yet to figure out what real value this adds to my skills and maturation as a physician. If this sort of content is to be included on the MCAT, the AAMC will have to do a much better job for it to be worthwhile and meaningful.

2) The MCAT is not the tool by which to evaluate candidates’ personalities. That’s what interviews, essays, and recommendations are for.

The MR5 recommendations continue.

To help medical schools consider data on integrity, service orientation, and other personalcharacteristics early in student selection, the AAMC should:13. Vigorously pursue options for gathering data about personal characteristics through a new section of the AMCAS application, which asks applicants to reflect on experiences that demonstrate their personalcharacteristics, and through standardized letters that ask recommenders to rate and write about behaviors that demonstrate applicants’ personal and academic characteristics.14. Mount a rigorous program of research on the extent to which applicants’ personal characteristics might be measured along with other new tools on test day, or as part of a separate regional or national event, or locally by admissions committees using nationally developed tools.

Lots of people think medical schools should look “beyond test scores” and focus more on “personality” when judging applicants. Dr. Pauline Chen, writing at the New York Times, thinks so. The UChicago medical student with whom I discussed this on Twitter thinks so. Many of my classmates think so. I probably think so as well, but then I can’t pretend to know how these decisions are actually made in real life as it is.

The idea that mastery of social science content (or lists of stereotypes, as seen above) correlates meaningfully to personality is dubious, to put it charitably. Also, with pre-meds being who they (we?) are, I’m skeptical that any dedicated “personality test” section on the MCAT would last more than a couple of years without being dissected, gamed, studied-for, and meaningless as a gauge of an applicant’s character.

If it’s personality that you want in your medical students, the MCAT is not how you’re going to sort them. If the AAMC wants to create standardized tools to help medical schools evaluate applicants without actually needing to interview them (as recommendation #14 seems to imply), then they should go for it. I would think, though, that different medical schools might want different types of students. A one-size-fits all assessment might not serve every school’s needs equally well.

If the MCAT is over-weighted in the admissions process, then the real issue is how it’s used, not what it tests. It’s also worth pointing out that as long as medical school deans care about their US News & World Report rankings, they will place non-trivial emphasis on their entering students’ MCAT scores. That’s a pretty big counterweight to any movement to increase the weighting of “personality” in medical school admissions.

(Briefly discussed later in this post: what personality traits do we want in all of our medical students, why do we want those traits, and are medical schools really being flooded with so many applicants who lack them?)

3) Medicine is about service, but it’s still an applied science.

A common theme in the reactions of some of my classmates (and Dr. Chen’s NY Times piece) is that the MCAT and/or the medical school admissions process is too heavily focused on mastery of science. (Did I mention that I was an Economics major?). While the science content of the MCAT could certainly stand to be tweaked, I would hesitate to write it off completely. It is still the best predictor of success in medical school (where “success” is “not failing out during the preclinical years”), and the only standardized means of comparing science ability across applicants. What has helped me get through the first year of medical school has not been my social science background (though it has helped). It’s been the solid science foundation that I got in undergrad alongside my economics coursework.

If students want to help others and save the world without needing to take those pesky, difficult science courses, there are plenty of other career options open to them. Medicine still requires comfort with science, and that is the reality that we’re stuck with for the foreseeable future.

3a) Barriers to entry to medicine should not be arbitrarily and artificially increased, but it’s worth pointing out that medicine is a field that requires dedication… or at least that’s what they told me.

This is a minor point, but an important one. In my cynical estimation, there are three sorts of people who would want to become practicing physicians in this day and age: the naive; the passionate; and the crazy. Medical training is a long and arduous process, and the practice of medicine in the US isn’t about to get easier in our lifetimes. If someone is discouraged from going into medicine because of the MCAT… what would they do when confronted with Step 1 of the USMLE? The MCAT isn’t a personality test and shouldn’t be used as one, but at the same time, my inner curmudgeon has to question the bona fides of those who claim they would go into medicine “but for the MCAT.” When my classmates tell me that these proposed changes will make the MCAT more accessible to students who otherwise wouldn’t have taken it, there is a part of me that wonders whether that is really an unalloyed good.

4) Is there another agenda at play here? (WARNING: SPECULATIVE)

Even as the debate goes on between social science upstarts and science purists, between those who think that “personality” is over- or under-represented as an admissions criterion, one could be forgiven for wondering what the fuss is all about.

Medical schools aren’t lacking for applicants. There isn’t, to my knowledge, an epidemic of death, destruction, bad outcomes, or other horrors brought about by physicians insufficiently knowledgeable about the social sciences. I doubt that most medical school graduates are uncaring, unsympathetic, offensive brutes.

The main “problem” with medical students today, as far as I can tell, is that too few of them are willing to go into primary care careers. At least… some people see it as a problem with the students. I don’t.

There’s been a lot of attention focused on the primary care shortage over the past few years, some of it focused on delivery reform (think ACOs and PCMHs), and some of it focused on supply (e.g. the medical students). One noteworthy report authored by the American Medical Association in 2007 intimated that the primary care shortage could be solved by finding medical students who are more “service-oriented” and “altruistic,” better able to “be advocates for […] social justice,” and less “autonomous.” The report proposes including “social accountability issues” among admissions criteria.

Implicit in all of this is the assumption that the problem with the health care system, and the cause of the primary care shortage, is that we’re the wrong kinds of medical students. I’ve blogged about this report before, and why its premises and conclusions on this issue are utterly wrong; I don’t need to re-hash this here.

I can’t help but wonder how much of this line of thinking went into the recommended MCAT changes. No one — not the AAMC, not the many commentators whose responses I’ve read — has explicitly made this connection. But the rhetoric is the same. The implicit assumptions seem to be the same. The same misguided goals via the same misguided methods.

I hope I’m reading too much into things, but if not I can only despair at the solutions that organized medicine has found for our problems.

I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”

Pro-union demonstrators — notably public school teachers — have flooded the state capital, Madison, to voice their displeasure with proposed cuts to pay, benefits, and collective bargaining ability. Meanwhile, a group of idealistic, enterprising physicians have set up shop to aid the protesters in their efforts. Given that these protests have been, fortunately, free from the violence wracking demonstrators in other parts of the world, these inspiring doctors have been using their special expertise for the benefit of the local protester community by writing the “sick notes” that will allow these teachers to keep their pay and jobs after having skipped work to attend the demonstrations.

As has been captured in many of the videos of the protests, these heroic physicians have been able to assess their new ”patients” in mere seconds, doubtlessly utilizing the speed-H&P skills learned by practicing medicine under the AMA-supported system of RVU-based payment.

In addition to showcasing the near-lightspeed pace at which the AMA believes outpatient medicine should be practiced, these doctors — from unlicensed resident to grizzled veteran of community practice alike — exemplify the values that will need to become more commonplace if primary care in the United States is to be revitalized.

As the voice of America’s doctors, and as the champions of primary care’s bright future as social justice advocacy, we are thrilled to see these Wisconsin physicians living up to the ideals espoused in the ITME recommendations, if not the Hippocratic Oath. The future of primary care is not in practicing medicine; it is in political agitation. These family practitioners are pioneering the way forward for their specialty. They are organizing for their community, and they are advocating for their patients’ sense of social justice, entirely unbound by the conventional problem-solving, clinical-assessment mentality that persists among primary care physicians at their own peril.

The American Medical Association stands with these brave primary care practitioners, and urges them to continue to practice primary care medicine in the best way possible. Only by following in their example can family physicians, outpatient internists, and pediatricians ”win the future” for their specialties in this environment of harsh RVU economics.

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In case you haven’t realized by now, this is not an AMA press release. It is a satire/parody of the AMA’s positions on medical education and physician supply in the context of the primary care shortage. Use of the AMA name is protected fair use. For more disclaimers, see my ”About” page.

Revulsion is not an argument; and some of yesterday’s repugnances are today calmly accepted — though, one must add, not always for the better. […] In crucial cases, however, repugnance is the emotional expression of deep wisdom, beyond reason’s power fully to articulate it.

If I held myself to such high standards, I would tell you that I find the thrust of what I see as mainline bioethical thought to be “icky,” and from thereres ipsa loquitur. However, I’d like to think that my distaste has more than mere “revulsion” behind it, and as such the matter is not so easily disposed of.

In the “standard” ethics and professionalism lectures, medical students are taught that medical ethics rest on three foundational pillars: non-maleficence (“do no harm”); beneficence (“do what’s best for your patient”); and autonomy (“act in accordance with your patient’s wishes”).

Who decides what’s best for the patient, or what constitutes harm? Logically, it should be the patient! When the stakes are high, so too should be the barriers for a physician to substitute his or her goals and values for the patient’s.

SUMS has a thriving medical ethics program, and we’ve had the opportunity to hear clinicians and medical ethicists from SUMS and from farther afield talk about ethical conundrums they’ve seen on the wards. Every presentation has shared one feature, without fail: it’s only an ethical conundrum (usually meriting a call to the bioethics committee) when the physician doesn’t agree with a patient’s choice, and has been unable to successfully use persuasion or coercion to change the patient’s mind.

This seems like a trivial observation at first. After all, why call the ethics committee to adjudicate a matter where the physician and patient are in perfect agreement (aside from rarer edge cases where this happens, usually involving experimental procedures)? It makes perfect sense!

What this means though, is that the medical ethicist has become the person to provide cover for a physician to override the patient’s autonomy. By virtue of selection bias in the cases they are asked to adjudicate, and the ever-present threat of regulatory capture, the role of “medical ethics” runs the risk of devolving into Paternalism 2.0. “We know what’s best for you, and if you don’t believe us, we’ll make you.” What’s more, when the medical ethicist is nothing more than the cudgel with which the physician forces his goals onto his patient, what claim does the ethicist then have to support his monopoly on decision-making in this sphere?

Admittedly, this image of medical ethics is a caricature. But to see the danger that lies in store, look no further than their cousins: the bioethicists.

So why has the medical ethics / bioethics enterprise come to undervalue patient autonomy so extensively? I offer two preliminary hypotheses.

First is the fact that medical ethics and bioethics are situated in an academic-institutional environment that usually leans left-liberal (Progressive). Whether the institution makes the people, or the people make the institution, it comes out to the same thing: the setting is one that inculcates a predilection for top-down technocratic control. I think that this assessment is valid, regardless of what you think of the merits of different political philosophies.

The second one is, in my mind, more interesting. Public choice theory reminds us that bureaucrats, leaders, institutions, and their people do not exist in a world devoid of incentives and personal agendas. As an ethicist, when you say “no,” you entrench the need for your services… there needs to be someone with the authority to say “yes,” and what better way to establish your authority then by saying “no?” When you posit increasingly more complex models for evaluating ethical dilemmas — “autonomy, beneficence, and non-maleficence” just don’t cut it — you create an institutional need for someone with expertise in dealing with these complex rules to act as interpreter, and thereby increase your own power and prestige. Giving full weight to patient autonomy would undermine the need for your services.

This isn’t to say that ethicists make decisions with an explicit eye to entrenching their influence in the medical setting. It is, however, a reminder that we should always be asking ourselves: quis custodiet ipsos custodes? Who watches the watchers?

That, and the “wisdom” of repugnance is only as valid as the reasoning that supports it. Having “a bad feeling” about something doesn’t cut it when lives are on the line.

There’s a central intellectual tension to be navigated during the first few months of medical school. On the one hand, there’s the desire to critically engage with the material, to think about it, and in some cases to challenge what we’re learning. On the other hand, there are some things you just have to know. All sorts of estimates abound as to the number of new terms to be learned in the first year of medical school — I’ve heard numbers in the thousands — and there comes a point where it doesn’t matter “why,” or “what more,” or “what if”… there are some things you just have to know.

This tension has so far manifested itself most clearly in the “soft” courses: the ones that try to teach ethics, professionalism, policy, “cultural competency,” “humanism,” and so on. SUMS has structured its ethics and professionalism courses quite interestingly. Small “discussion” groups get together to consider scenarios and watch media clips — some chosen from mass media, some from actual clinical practice — designed to prompt “discussion.” Invariably, these clips have been trite, facile, and chosen to allow only one “correct” answer: be nice to nurses; care about the patient; the patient is more than a disease; you need to see the patient to learn from the patient; don’t get in the attending’s way during a tricky surgery; etc.

If you’ve never been told these sorts of things before, it’s important to hear them, intuitive though they should be. Given the abundance of rhetoric from SUMS administrators about the importance of “reflection” in medical education, it’s a shame that no such opportunities are provided when considering the maxims of professionalism handed down from on high. After all, it’s the exceptions that prove* rules, and it’s the exceptions that give rise to the hardest questions, deepest thought, and ultimately the best engagement with and internalization of these norms.

Take, for instance, one of the many clips from medical shows depicting an arrogant young intern ignoring and/or being rude to nurses and other support staff. Obviously, one should not ignore or be rude to nurses or support staff. But what happens when there’s a legitimate difference of opinion? Who’s ultimately accountable for the patient’s care, and how should the decision-making and teamwork process go from there? What if someone is advocating for something that is just plain wrong? These things happen. Hiding behind a series of feel-good maxims about professionalism doesn’t prepare anyone for the tradeoffs they will encounter in the real world.

The reason I started thinking about this again was because of some remarks made by a SUMS assistant dean at our latest class meeting. As I’ve written before, at SUMS the threshold for “official professionalism incident reports” to be placed in the files that get sent to residencies can potentially be pretty low; even minor lateness to class or with administrative deadlines could potentially be punished this way.

At this meeting, the dean provided, sua sponte, an attempted justification for the breadth of this policy, and the school’s apparent willingness to make use of it (fortunately, this isn’t known to me firsthand). According to him, studies have found correlations between medical school disciplinary action and state medical board action; the biggest predictors of subsequent license sanctions for medical students are apparently” irresponsibility” and “diminished ability to improve or take criticism.”

These are bad things, and it’s not surprising that these traits in medical students would be correlated with subsequent disciplinary action as physicians. Nonetheless, part of me still wonders if this correlation might not suggest causation.

When ethics and professionalism are treated as Platonic Maxims to be taken as dictated from the Faculty Above, with no room for thought, discussion, criticism, or engagement, might not a medical student facing sanction for unprofessional conduct — particularly if that conduct is a minor instance of tardiness — become disengaged from the entire set of ideals that professionalism is supposed to represent, thereby becoming more prone to major breaches later in life?

When ethics and professionalism, instead of representing the ideals of meaningful commitment to patients, come to be associated with arbitrary-seeming exercises of power by medical school administrators or as ways of stifling legitimate discussion about the role and behaviours of physicians, might not a student learn to distrust these concepts later in life?

When students are threatened with inflated artificial sanctions in lieu of facing the actual consequences of their actions, what does it teach them about autonomy?

I usually don’t display these sorts of blatantly anti-authoritarian leanings, and I’m not asking these questions to cause a ruckus or make a point of any sort. I’m legitimately curious, and mildly concerned, about the implications of this approach to the teaching of ethics and professionalism to medical students.

These are the sorts of questions I would have loved to have asked him. I might have even started a conversation that would have been so informative as to alleviate my concerns entirely, or maybe raise them in his mind. Such potentially valuable exchanges of ideas, however, will have to wait until I’m actually permitted to initiate them.

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* – I use “prove” here in the sense of “demonstrating the existence of the rule” but also in the sense of “testing the boundaries, applicability, and viability of the rule.”